Halal Brand Is an Effective Solution for the Development of Medical Tourism : A Case Study of Hospital Hotel

Introduction ospital hotel is a relatively new topic. Hospital hotel can provide the opportunity for family and relatives to stay alongside the patient, which is a positive factor for the course of the disease and accelerates the patient's recovery. In many countries, tourism is the main driving force behind economic growth (1). The industry, with more than 1.5 trillion income, is currently an industry that accounts for 7% of the revenues from the export of goods and services, comprising a larger contribution than those of food and vehicle industries. This industry has created 120 million direct and indirect jobs worldwide. Experts predict that the tourism industry will become the most profitable industry worldwide up to 2020 (2,3). Among the various forms of tourism, health tourism has drawn significantly more attention due to its competitive capacities and advantages, and continues to grow rapidly (4). Health is the product demanded for in health tourism and in turn causes demand for tourismrelated components, such as transportation and accommodation. Therefore, its growth implies simultaneous demand for both the healthand tourism-related components (5). According to the World Tourism Organization’s definition of tourism, health tourism addresses three dimensions; time, place and purpose of travel. Therefore, the World Health Organization constitution defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Therefore, health tourism means travel to outside the H Abstract


Introduction
ospital hotel is a relatively new topic.Hospital hotel can provide the opportunity for family and relatives to stay alongside the patient, which is a positive factor for the course of the disease and accelerates the patient's recovery.In many countries, tourism is the main driving force behind economic growth (1).The industry, with more than 1.5 trillion income, is currently an industry that accounts for 7% of the revenues from the export of goods and services, comprising a larger contribution than those of food and vehicle industries.This industry has created 120 million direct and indirect jobs worldwide.Experts predict that the tourism industry will become the most profitable industry worldwide up to 2020 (2,3).Among the various forms of tourism, health tourism has drawn significantly more attention due to its competitive capacities and advantages, and continues to grow rapidly (4).Health is the product demanded for in health tourism and in turn causes demand for tourismrelated components, such as transportation and accommodation.Therefore, its growth implies simultaneous demand for both the health-and tourism-related components (5).According to the World Tourism Organization's definition of tourism, health tourism addresses three dimensions; time, place and purpose of travel.Therefore, the World Health Organization constitution defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.Therefore, health tourism means travel to outside the normal life environment for a maximum of one year, with the aim of maintaining, improving or recovering physical and mental health (6).Health tourism can be divided into three forms: Medical tourism: A journey to treat a physical disease or perform a doctor-supervised surgery in hospitals or other health facilities; therapeutic tourism: A journey for the treatment of a specific disease while undergoing the recovery under the supervision of a doctor by using natural resources in health such as mineral and hot springs, salt lakes, the sun, radioactive sands, sludge and climate therapy (7); Health or preventive tourism: Traveling to escape from the stressors of daily life and rehabilitate without medical intervention and supervision (the tourist does not have any kind of discomfort and physical illness) in health villages and spas (where mineral water or sea water is used for therapeutic bathing), and usually entails the health services using mountain plants, ponds and springs (8,9).Halal is a Quranic word meaning authorized and legitimate.In the Quran, the Muslim celestial book, many verses describe this concept.Forty one of the verses of the Quran are related to halal food and drinks (10).Halal is a broad concept that encourages Muslims to adopt products that promote goodness in all aspects of life, are healthy for consumption and are produced in a healthy and clean environment (11).Islamic or halal branding have been developed based on Islamic principles and lead customers toward using authorized services and affairs, not only in the food industry, but also in other industries such as pharmaceutical, cosmetic, clothing and banking and financial services industries.Companies and organizations that seek to target the Muslim market require different marketing strategies.Their strategies must be in line with Islamic values, standards and teachings, and they must consider various factors that can affect the success of their operations in the Islamic market (11,12).Wilson and Liu have considered the brand theory to be associated with religion or Islam, and have argued that brands are created because their owners seek to encourage consumption, support and the formation of a relationship, and lead eventually to praise.Some of the brands, independently or collectively, will lead to a good like status (13).As a result, Halal branding in therapeutic tourism is a process by which a company or business seeks to distinguish its products and services using a name, symbol, design or some combination from other businesses and informs the consumers of this attempt (14,15).Although Iran is an Islamic country and attention must be constantly paid to the provision of halal services and avoidance of haram (religiously illegitimate) services in the hospitals in this country, little effort has so far been made in the area of halal therapeutic tourism in both academic research and practice.Therefore, the purpose of this study is to help one of the new therapeutic tourism services, i.e. hospital hotel, to become an international brand with an emphasis on halal services in order to contribute to Iran economic prosperity and health tourism.

Methods
The purpose of this study is to identify the dimensions of the halal branding of hotel hospitals.Therefore, this research is basic or exploratory with respect to purpose, and qualitative with an inductive approach from methodological perspective.Data were analyzed by thematic analysis.
In this research, the main format of data collection was semi-structured and in-depth interviews.Considering that no study, to the best of our knowledge, has yet been conducted to investigate the dimensions of the halal hotel hospital in Iran, samples were selected from all patients, accompanying persons, and staff of the Gandhi and Crescent Hospitals in Tehran, Iran based on the researchers decision.A total of 20 interviews were conducted.First, four staff of the hotel hospitals (P1,P2,P3,P4), consisting of the chief executive officer, the director of the International Patient or Medical Tourists Department (IPD), the IPD physician and the hoteling manager and then four patients (P5, P6, P7 and P8) and four accompanying persons (P9,P10,P11,P12) were interviewed.Next, three staff of the hospital Downloaded from jhsme.muq.ac.ir at 22:12 IRST on Tuesday December 11th 2018 hotels (P13,P14,P15), three patients (P16,P17,P18) and two accompanying persons (P19,P20) were interviewed.Although data saturation was achieved in the interview no.14, we conducted 20 interviews.
All participants signed informed consent form without any coercion, threat and seduction.The procedure, purpose and duration of the study were explained to the participants.They were also assured that they could withdraw from the study whenever they wished.
Thematic analysis was used to draw themes from texts and resources.Thematic analysis is, in fact, a type of inductive approach to analyze qualitative data that is based on the units of the theorized theme.Sterling, in his categorization of the themes, identified three types of themes: Basic, organizing, and inclusive.He also argued that by analyzing the content, a network of themes is created and, by analyzing them, the main themes are drawn and the model is finally explained (16)(17)(18).
The data analysis process began with open coding (19).First, the basic themes in question were sought out.Open coding is an analytical process where identifiable concepts and features and dimensions of all concepts are discovered.In open coding, events or things observed in the data are coded, and the main focus is on understanding the characteristics that have led to the uniqueness of these events.

Result
After transcribing the interviews and refining the transcripts, over 110 themes were drawn (Table 1).
Next, the researchers discovered two general orientations within the themes (primary codes) (Table 2).One orientation was concerned with whether the codes were material or spiritual?Spiritual requirements mean those requirements that are compatible with Islamic culture and context and specific to halal hotel hospitals, including serving halal foods, observing Islamic dressing, facilitating worship during stay and treatment, not performing abortion and the availability of prayer room in the facilities.Overall, 47 codes were derived as to be related to spiritual requirements and 63 codes were found to be material requirements.
Material codes including the availability of sufficient protective staff, the availability of a swimming pool and the cleanliness of corridors are a prerequisite for the success of such organizations irrespective of being halal or otherwise.
The other drawn orientation was the time orientation of the codes.This means that some of the requirements are those that customers are dealt with on a daily basis, while others are comparatively longer-term requirements and senior executives should consider appropriate policymaking for them and meeting them in the long-term.For example, out of the spiritual dimensions, using the capacity of consulting religious organizations requires provision of a suitable context and extensive negotiations between the hospital hotels and the religious organizations, taking a long time to have an outcome.Similarly, constructing buildings with Islamic architecture is not realized in the short term; or obtaining a Halal Certificate Services is a specific requirement for a hotel hospital that has concern for halal services, requiring it to make necessary arrangements with the entities issuing these certificates and to provide sample services and products to be examined by these entities.
It is therefore a long-term requirement.But, although Putting the prayer veil in rooms is a spiritual requirement, this measure is simple and affordable and does not require long-term coordination; or certain measures such as the development of appropriate guidelines, the availability of Qiblalocator and the installation of religious icons can be taken in the short term.

Discussion
Given that many countries have entered the competition in health tourism, the level of competition in this area is very high.Therefore, the need for differentiation from competitors has been intensified.From marketing perspective, differentiation is conducted by branding and identifying brand is one of the requirements distinguishing brand.Although Iran is an Islamic country and attention must be constantly paid to the provision of halal services and avoidance of Downloaded from jhsme.muq.ac.ir at 22:12 IRST on Tuesday December 11th 2018 haram (religiously illegitimate) services in the hospitals in this country, little effort has so far been made in the area of halal therapeutic tourism in both academic research and practice.Therefore, a distinct brand across countries can be achieved with the proper planning and emphasis on the legitimacy of the services, and our research was a step in this direction.
Since no similar research has yet been conducted to investigate this subject, it is not possible to interpret the results of this study with reference to those of other studies.The studies of Scott & Jafari and Alserhan have only outlined a number of halal services and products related to medical tourism (11,20); and Medhekar and Haq only mentioned a number of cultural sensitivities of Muslim patients (15).
But in this study, we used a qualitative research method to investigate the viewpoints of the target population, without considering Table 1.Some examples of the codes drawn from interview transcripts Basic themes

Interview transcript Interviewee
Halal Food Suppliers The foods should be demanded for from the suppliers whose production process has been verified as Halal.

P2,P3,P15
Using Islamic design In my opinion, the way of painting and molding and overall the architecture of the facilities should be traditional and Islamic.

P1,P2,P19
Not being extravagant in prescribing medicine Both doctors and pharmacists should be committed to prescribing drugs in sufficient amount and shouldn't be extravagant in [prescribing] drugs due to more sales or other issues.

Not exhibiting nude artworks
As far as I can tell, certain paintings and photographers should not exist, for example [those] that are nude.

P5,P6,P9,P16, Preventing abortion without permission
There must definitely be rules in accordance with Islamic Sharia.For example, no abortion should be done without the permission of the respective institutions.

P1, P2, P15
Providing Islamic books In my opinion, in both hospital setting and hoteling section, some shelves should be placed to place Islamic books such as the Quran and Mafatih[-ul-Jinan] and some of the books of religious elders that people could use and return. P2,P3,P14,P20 Observing the privacy of the patient's companions Because of family or friends accompanying patients, personal privacy policies should also be developed.

P5,P6,P11,P16
Not serving haram drinks You need to be careful about things that may not be a problem in other countries, such as serving haram drinks.

P4,P14,P9,P17
Not serving haram meat You need to be careful about things that may not be a problem in other countries, such as the discussion of the religious legitimacy of animals [meat] and their slaughter.

P3,P12, P13
Male staff for male patients When I, myself, call the nurse and have something [to do], I prefer a male nurse to come, so it's easier to express wishes.

P6, P8, P11
Installing religious icons at accommodation [When] I see these pictures of the shrine of Imam Reza (AS), I feel a special peace.P6,P7,P10,P19

Observing Islamic dressing
Here, employees are well-dressed, especially the women, and all have perfect and appropriate hijab.
P3,P13,P14, P17 Providing prayer carpet and prostration (sajdah) counter One should also consider equipping the room of the companions, some things such as prayer-carpet, etc. are necessary to provide. P5,P6,P9,P18

Preparing the budget through the loan
To the credit of the halal name (brand), care must be taken in meeting the financial needs.Using any financial opportunity should be avoided.For example, we should not take loans with high profits that, according to some marājiʿ (references to follow), are doubtful.Instead, you can count on mortgage loans. P1,P3,P4,P13

Funding by benefactors and charities
To the credit of the halal name (brand), care must be taken in meeting the financial needs.For example, a number of benefactors should be found to meet some amount of financial needs. P1,P3,P4,P13

Developing regulations based on Islamic rules
In my opinion, for developing the rules clerics and religious advisers could be hired.For example, a group [could be] formed without its final endorsement none of the rules [could be] approved.

Separate rooms for women
The availability of special spaces for every gender is also a good thing, for example separate waiting rooms for women and men.(11).
Torabi conducted a study on the status of Halal branding, especially halal tourism in the world and Iran, to develop a conceptual model for its development.In that descriptivecorrelational study, reviewing the verses and narrations regarding tourism, the researcher concluded that the main purposes of journey, according to religious principles, are travelling and credit, on which the primary research model was based, and then the final model consisting of the components of travel and credit, religious thought, religious background and religious mankind was developed (21).
Shahnazari in his study entitled Designing a Model for Promoting Halal Branding Position in Global Markets, identified 28 macrovariables divided into four categories, structural, behavioral, content and strategic (10).
Shirkhodai and Nooripoor conducted a research on the role of attitudes toward halal brand certificate in creating a special value, showing that attitude toward halal certificate had a positive and significant effect on awareness and perceived quality of brand, but the effect of such attitude on the association between brand loyalty and halal food was not confirmed (22).
Fazil conducted a study to create and manage halal branding based on the personality dimension of halal brand in Malaysia.In that research, the experts were interviewed, and the results led to development of a theoretical framework for halal brand identity with five dimensions; purity, excitement, safety, complexity and justice (23).

Conclusion
In this research, we used a qualitative research method to investigate the viewpoints of the target population, without considering the available evidence from western communities to be presumption, Finally, the research model was a two-dimensional model because the participants' statements were a combination of two orientations.
The results of this research provide a new perspective for the Tourism and Handicrafts Organization, the World Halal Institute, the Chamber of Islamic Commerce, Industry and Agriculture and the Islamic Chamber Research and Information Center, because there are three main steps in branding, consisting of brand strategy, brand integrity and brand differentiation.At the step of determining the brand strategy, the brand name, logo, tagline, etc. are addressed, and at the level of brand integrity, the brand's relationship with sale, services and customer experiences is considered, and finally by means of certain tools such as media, website, brochure and video marketing, the brand will come to the step of informing and executing.
But before these steps, we have to choose an appropriate conceptual model to achieve, including the one our study presented.Therefore, the organizations involved in the policymaking of health tourism can use this model and finalize the next steps of branding and halal therapeutic tourism program.
The present study was carried out in a specific time and location that comprise one of its limitations.The medical tourists who were Downloaded from jhsme.muq.ac.ir at 22:12 IRST on Tuesday December 11th 2018 interviewed in this study were all Muslims of the Persian Gulf states.It is therefore recommended to replicate this study with medical tourists from other neighboring countries, such as the Caspian Sea states, who select Iran as the destination, and to interpret their findings with reference to our observations.

Table 2 .
Final model of study